RADIOLOGICAL IMPACT OF USING DECORATIVE GRANITE AS AN ATTENUATOR OF IONIZING RADIATION.

Granite is a widely available rock, which can be used as a shielding material, for bulk in the form of the aggregate in concrete. It has the weakness that it is more radioactive than many other rocks, which can be used in concrete. This paper looks at its properties as a shielding material and the activity level. Thus, the concentrations of 226Ra, 232Th and 40K, in granite were measured using a high pure germanium detector (HPGe). They were ranged from (15 ± 4 to 49 ± 5) Bq kg-1 for 226Ra, (22 ± 4 to 78 ± 4 Bq kg-1) for 232Th and (791 ± 13 to 1231 ± 15 Bq kg-1) for 40K. Radiological indices of radium equivalent concentration (Raeq), external (Hex), internal (Hin) and annual effective dose were less than worldwide recommended limits. The results emphasized, the granite samples had no radiation hazard. Nevertheless, the mass attenuation coefficients of granite samples were measured for the gamma rays of energy range 122-1408 keV. The mass attenuation coefficients of the studied granite samples were ranged from 0.05 to 0.15 cm2 g-1. In addition, the average the half-value layer of granite was varied from 1.8 cm for 122 keV to 5.2 cm for 1408 keV. The results are that the attenuation characteristics are typical and match the values given by NIST for 'concrete' and that the activity levels of the samples examined are acceptable. Thus the granite may be used as an attenuator for ionizing radiation.

A Longer Route to the PICU Can Lead to a Longer Stay in the PICU: A Single-Center Retrospective Cohort Study.

INTRODUCTION: Admission to the pediatric ICU versus general pediatric floor for patients is a significant triage decision for emergency department physicians. Escalation of care within 24 hours of hospital admission is considered as a quality metric for pediatric E.R. There exists, however, a lack of data to show that such escalation leads to a poor outcome. METHODS: A retrospective cohort study was conducted to compare outcomes of patients who required escalation of care within 24 hours of hospital admission to the pediatric ICU (cases) from 01/01 2015 to 02/28 2019 with those who were directly admitted from emergency department to the PICU (controls). A total of 327 cases were compared to 931 controls. Univariate and multivariable regression analysis was done to compare the length of stay and mortality data. RESULTS: Patients who required escalation of care were significantly younger (median age 1.9 years compared to 4.6 years for controls) and had lower severity of illness score (PIM 3). Cases had a much higher proportion of respiratory diagnosis. ICU length of stay, hospital length of stay and the direct cost was significantly higher for cases compared to controls. This difference persisted for all age groups and respiratory diagnosis. The cost of care, however, was only different for 1-5 years and >5 years age groups. The difference in ICU length of stay (Δ11.1%) and hospital length of stay (Δ7.8%) persisted on multivariate regression analysis after controlling for age, sex, PIM3 score, and diagnostic variables. There was no difference in mortality on the univariate or multivariate analysis between the 2 groups. CONCLUSIONS: Patients who required escalation of care within 24 hours of hospital admissions have more prolonged ICU and hospital stay and potentially increased cost of care. This measure should be considered while making patient disposition decisions in the emergency department.

Acute Myocardial Ischemia Following Bee Sting in an Adolescent Male: A Case Report.

BACKGROUND Epinephrine for anaphylactic shock is the standard life-saving treatment in the emergency department. Cardiac symptoms after epinephrine administration in a child with no prior cardiac history are often not suspected. We describe a presentation of diastolic cardiac dysfunction after anaphylaxis from a bee sting in an adolescent male. CASE REPORT A 16-year-old male with no prior history of allergy presented with anaphylaxis following a bee sting. The patient received an inadvertent intravenous rather than intramuscular dose of 1: 1000 epinephrine, leading to myocardial ischemia. Diastolic dysfunction resulting from myocardial ischemia and fluid resuscitation led to development of pulmonary edema. The patient required epinephrine drip for hemodynamic support and BiPAP for respiratory support. CONCLUSIONS This case highlights the risk of giving a rapid intravenous push of epinephrine, which converted an anaphylactic reaction to cardiogenic shock. Anaphylaxis-related coronary ischemia (Kounis) syndrome is another less likely etiology for our patient's presentation.

A FEASIBILITY TEST FOR QUICK RADON RISK ASSESSMENT BY MEASURING AN IN SITU RADIATION DOSE RATE.

Radon concentration was estimated using an accumulation chamber equipped with AlphaGUARD radon monitor. It varies from 12.6 ± 1.20 to 363 ± 19.3 Bq m-3 with a mean value of 180 ± 11.2 Bq m-3. A good correlation between radium content and radon concentrations was obtained of R = 0.754, which suggests that radium is the main reason of releasing radon to the atmosphere. Radon emanation coefficient and exhalation rate were also calculated. Furthermore, the radiation dose rate was measured with a high-pressure ionization chamber detector. The radiation dose rate was strongly correlated with the radon concentration and exhalation rate of R = 0.85 and 0.63. The obtained results support our idea that the radiation dose rate can be a good indicator to the radon level in the atmosphere. In addition, the dependence of radon concentration on the water content was discussed.

Pediatric cervical spine injuries on CT: difference in accuracy of interpretations by pediatric versus non-pediatric radiologists.

PURPOSE: To retrospectively compare the accuracy of interpretation of initial cervical computerized tomography (CCT) by a non-pediatric radiologist (NPR) versus a pediatric radiologist (PR). METHODS: IRB approval and consent waiver were granted to review all injured children from 2010 to 2014 in the trauma registry with CT and magnetic resonance imaging (MRI) of the cervical spine. Patients with negative CCT who subsequently had positive MRI from a single institution comprised the study group. Patients with negative CCT and MRI, matched by age, gender, and severity scores, comprised the control group. The CCTs from both groups were initially interpreted at the time of service by a NPR. Subsequently, a single PR with 20 years of experience blinded to clinical/imaging data reinterpreted these CCT examinations. CT interpretations were then compared with MRI results and evaluated for statistical significance using SSPS software. The data analysis utilized summary statistics, two-tailed binomial test, and univariate χ2 test. Significance for all comparisons was assessed at P < 0.05. RESULTS: The study group was comprised of the 21 patients with negative CCT and positive MRI. Of the cohort included, 76% (16) were male and 24% (5) were female. The age range was 1 month-17 years, with a mean age of 9.7 years. CCT interpretation by NPR had a specificity of 91.7% (sensitivity 71.2%, positive predictive value 81.3%, and negative predictive value 86.3%) compared with results of MRI. Six of the 21 negative CCTs were interpreted by the PR as positive, mainly craniocervical junction injuries, and confirmed by MRI (28.6%, P < .001 compared with the NPR); no control CCT was interpreted by the PR as positive (sensitivity 100%, positive predictive value 100%, and negative predictive value 58.3%). CONCLUSION: In our retrospective study, a pediatric radiologist has improved recognition of pediatric cervical spine injuries on CT compared with non-pediatric radiologist.

ASSESSMENT OF RADIOLOGICAL HAZARDS OF USING PETROLEUM RAW MATERIALS AND THEIR WASTE.

Activity concentrations of 238U, 232Th and 40K in raw and waste petroleum materials (Egypt and Kuwait) were measured using gamma ray spectrometer. The average values of 226Ra, 232Th and 40K were 21.1 ± 3.2, 7.6 ± 1.3 and 88.4 ± 8.2 Bq kg-1 for Egyptian samples while for Kuwaiti samples, they were 25.2 ± 3.4, 6.1 ± 2.2 and 67.8 ± 6.4 Bq kg-1, respectively. All samples had activity less than the exemption level recommended by the International Atomic Energy Agency. Moreover, radiological indices of radium equivalent, external, internal, alpha and gamma indices and radiation dose as well were calculated and their values were lower than the recommended regulatory limits. Thus, radiation exposure to petroleum materials did not present a significant radiological hazard.

Measurement of Intraoperative Blood Loss in Pediatric Orthopaedic Patients: Evaluation of a New Method.

INTRODUCTION: Our goal was to validate a new method of intraoperative blood loss measurement in pediatric patients who undergo orthopaedic surgery. METHODS: We prospectively collected surgical sponges from 55 patients who underwent pediatric posterior spinal fusion, single-event multilevel surgery, or hip reconstruction for measurement of intraoperative blood loss. We enrolled patients if expected estimated blood loss (EBL) was >200 mL. The methods used for blood loss assessment included the Triton sponge scanning system, visual method, gravimetric method, and measured assay (reference) method. RESULTS: The Triton system calculation of cumulative EBL per patient against the reference method yielded a strong positive linear correlation (R2 = 0.88). A weaker correlation was noted between the gravimetric method and reference EBL (R2 = 0.49). The Triton system had a low bias and narrow limits of agreement relative to the reference method (49 mL; 95% CI, 30 to 68). The gravimetric method had a higher bias and wider limits of agreement (101 mL; 95% CI, 67 to 135). The comparison of visual total EBL against the reference method yielded a notable discrepancy. DISCUSSION: Estimated blood loss measured using the Triton system correlated better with the reference method than with the gravimetric method. The visual estimation method was found to be inaccurate. Intraoperative use of the Triton system is convenient and precise for monitoring intraoperative blood loss.

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

OBJECTIVES: To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN: Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children. SETTING: Not applicable. INTERVENTION: None. SUBJECTS: Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion. METHODS: A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. MEASUREMENTS AND RESULTS: The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations. CONCLUSIONS: The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

OBJECTIVES: To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS: The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated. CONCLUSIONS: The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.

Hemoglobin Levels Across the Pediatric Critical Care Spectrum: A Point Prevalence Study.

OBJECTIVES: To determine the prevailing hemoglobin levels in PICU patients, and any potential correlates. DESIGN: Post hoc analysis of prospective multicenter observational data. SETTINGS: Fifty-nine PICUs in seven countries. PATIENTS: PICU patients on four specific days in 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients' hemoglobin and other clinical and institutional data. Two thousand three hundred eighty-nine patients with median age of 1.9 years (interquartile range, 0.3-9.8 yr), weight 11.5 kg (interquartile range, 5.4-29.6 kg), and preceding PICU stay of 4.0 days (interquartile range, 1.0-13.0 d). Their median hemoglobin was 11.0 g/dL (interquartile range, 9.6-12.5 g/dL). The prevalence of transfusion in the 24 hours preceding data collection was 14.2%. Neonates had the highest hemoglobin at 13.1 g/dL (interquartile range, 11.2-15.0 g/dL) compared with other age groups (p < 0.001). The percentage of 31.3 of the patients had hemoglobin of greater than or equal to 12 g/dL, and 1.1% had hemoglobin of less than 7 g/dL. Blacks had lower median hemoglobin (10.5; interquartile range, 9.3-12.1 g/dL) compared with whites (median, 11.1; interquartile range, 9.0-12.6; p < 0.001). Patients in Spain and Portugal had the highest median hemoglobin (11.4; interquartile range, 10.0-12.6) compared with other regions outside of the United States (p < 0.001), and the highest proportion (31.3%) of transfused patients compared with all regions (p < 0.001). Patients in cardiac PICUs had higher median hemoglobin than those in mixed PICUs or noncardiac PICUs (12.3, 11.0, and 10.6 g/dL, respectively; p < 0.001). Cyanotic heart disease patients had the highest median hemoglobin (12.6 g/dL; interquartile range, 11.1-14.5). Multivariable regression analysis within diagnosis groups revealed that hemoglobin levels were significantly associated with the geographic location and history of complex cardiac disease in most of the models. In children with cancer, none of the variables tested correlated with patients' hemoglobin levels. CONCLUSIONS: Patients' hemoglobin levels correlated with demographics like age, race, geographic location, and cardiac disease, but none found in cancer patients. Future investigations should account for the effects of these variables.

Patient Blood Management in Pediatric Cardiac Surgery: A Review.

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Reply: Intravenous Ferumoxytol in Pediatric Patients With Iron-Deficiency Anemia.

Iron Deficiency in children is common problem. Its mechanism could be nutritional or due to lack of iron absorption. Several conditions are associated with IDA. Presence of inflammation further complicate attempts to make a definitive diagnoses or accurately quantify reponse to therapy.

Intravenous Ferumoxytol in Pediatric Patients With Iron Deficiency Anemia.

BACKGROUND: Iron deficiency anemia (IDA) is common in children. Limited data exist on the efficacy and safety of ferumoxytol in children. OBJECTIVE: To assess the efficacy of 10 mg/kg dose given over 15-60 minutes in correcting IDA and report any adverse drug reactions (ADRs). METHODS: We conducted a retrospective review of all patients who received ferumoxytol infusions for the management of IDA by the Pediatric Blood Management Program between October 2010 and March 2015. RESULTS: A total of 110 infusions were given to 54 patients. Compared with baseline preinfusion hemoglobin (Hb; 9.2 ± 1.9 g/dL), a significant rise was seen at 1 week and 4 weeks postinfusion (11.5 ± 1.5 and 11.8 ± 1.7 g/dL, respectively, P < 0.001). Also, a significant rise in serum ferritin at 1 week and 4 weeks postinfusion was seen (51 ± 71 vs 192 ± 148 and 89 ± 135 ng/mL, P < 0.001 and <0.035, respectively). Patients who concomitantly received erythropoietin had a significantly larger Hb rise from baseline than those who did not at 4 weeks (2.7 ± 2.2 vs 1.6 ± 1.1 g/dL, P < 0.017). ADRs included pruritus (n = 1), urticaria (n = 1), and multisymptom episodes (n = 3) that included shortness of breath, chest tightness, back pain, and epigastric cramping that responded to therapy with IV diphenhydramine and methylprednisolone. CONCLUSION: Ferumoxytol was effective in treating IDA in our small study. Slow infusion rate and close monitoring allowed early detection of the infrequent ADRs.

Full core analysis of IRIS reactor by using MCNPX.

This paper describes neutronic analysis for fresh fuelled IRIS (International Reactor Innovative and Secure) reactor by MCNPX code. The analysis included criticality calculations, radial power and axial power distribution, nuclear peaking factor and axial offset percent at the beginning of fuel cycle. The effective multiplication factor obtained by MCNPX code is compared with previous calculations by HELIOS/NESTLE, CASMO/SIMULATE, modified CORD-2 nodal calculations and SAS2H/KENO-V code systems. It is found that k-eff value obtained by MCNPX is closer to CORD-2 value. The radial and axial powers are compared with other published results carried out using SAS2H/KENO-V code. Moreover, the WIMS-D5 code is used for studying the effect of enriched boron in form of ZrB2 on the effective multiplication factor (K-eff) of the fuel pin. In this part of calculation, K-eff is calculated at different concentrations of Boron-10 in mg/cm at different stages of burnup of unit cell. The results of this part are compared with published results performed by HELIOS code.

Red cell transfusions as an independent risk for mortality in critically ill children.

BACKGROUND: Severity of illness is an important consideration in making the decision to transfuse as it is the sicker patient that often needs a red cell transfusion. Red blood cell (RBC) transfusions could potentially have direct effects and interact with presenting illness by contributing to pathologies such as multi-organ dysfunction and acute lung injury thus exerting a considerable impact on overall morbidity and mortality. In this study, we examine if transfusion is an independent predictor of mortality, or if outcomes are merely a result of the initial severity as predicted by Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM2), and day 1 Pediatric Logistic Organ Dysfunction (PELOD) scores. METHODS: A single center retrospective study was conducted using data from a prospectively maintained transfusion database and center-specific data at our pediatric ICU between January 2009 and December 2012. Multivariate regression was used to control for the effects of clinical findings, therapy, and severity scores, with mortality as the dependent variable. Likelihood ratios and area under the curve were used to test the fidelity of severity scores by comparing transfused vs. non-transfused patients. RESULTS: There were 4975 admissions that met entry criteria. In multivariate analysis, PRISM III scores and serum hemoglobin were significant predictors of transfusion (p < 0.05). Transfused and non-transfused subjects were distinctly disparate, so multivariate regression was used to control for differences. Severity scores, age, volume transfused, and vasoactive agents were significantly associated with mortality whereas hemoglobin was not. A substantial number of transfusions (45 %) occurred in the first 24 h, and patients transfused later (24-48 h) were more likely to die compared to this earlier time point. Likelihood ratio testing revealed statistically significant differences in severity scoring systems to predict mortality in transfused vs. non-transfused patients. CONCLUSIONS: This study suggests that RBC transfusion is an important risk factor that is statistically independent of severity. The timing of transfusions that related strongest to mortality remained outside the purview of severity scoring, as these happened beyond the timing of data collection for most scoring systems.

Effect of pretransplant hepatitis C virus on the development of new-onset diabetes mellitus after transplant in Egyptian living-donor renal allotransplant recipients at Mansoura Urology and Nephrology Center.

OBJECTIVES: New-onset diabetes mellitus after transplant is a common complication in renal allograft recipients. Recently, a high prevalence of diabetes mellitus has been reported in patients with chronic hepatitis C virus. The association between hepatitis C and diabetes mellitus is well demonstrated in the general population, but some controversy still exists. This work aimed to study the effect of pretransplant hepatitis C virus on the development of new-onset diabetes mellitus after transplant in Egyptian living-donor renal allotransplant recipients. MATERIALS AND METHODS: This retrospective single center study included 913 kidney transplant recipients who were transplanted at Mansoura Urology and Nephrology Center between 2000 and 2010. The patients were divided into 4 groups according to their hepatitis C virus serology and diabetic status. RESULTS: Pretransplant dialysis duration and number of blood transfusion units were statistically significant among both viremic and nonviremic groups. With respect to induction therapy, a highly statistical significance was observed between the 4 groups regarding presence and type of adjuvant therapy (P < .001). With respect to maintenance immunosuppression, high statistically significant results were observed regarding steroid and rapamycin between the 4 groups (P < .001) with lower significance regarding mycophenolate mofetil (P = .04) but no significance regarding azathioprine, cyclosporine, or tacrolimus therapy. Incidence of new-onset diabetes mellitus after transplant was statistically higher in the viremic than nonviremic group (P < .001). CONCLUSIONS: There was a positive correlation between incidence of new-onset diabetes mellitus after transplant and positive pretransplant hepatitis C virus status.